Intravenous (IV) therapy is a common medical procedure, but it carries the risk of a complication known as extravasation, which occurs when fluid or medication leaks from the vein into the surrounding tissue. This event is distinct from infiltration, where the leaked fluid is non-irritating, because extravasation specifically involves a vesicant drug that can cause severe tissue damage. The chemical properties of these agents, such as extreme pH or high osmolarity, trigger a cytotoxic reaction in the soft tissue. If not identified and managed rapidly, extravasation can lead to serious consequences, including localized tissue necrosis, permanent nerve damage, and potentially limb-threatening compartment syndrome. Strict adherence to established protocols is necessary to prevent these serious injuries during drug administration.
Pre-Procedure Assessment and Site Selection
Preventing extravasation begins with a thorough pre-infusion assessment of the patient and the intended vascular access site. Patient history is important, as previous IV difficulties, compromised circulation, or conditions like diabetes that affect vein integrity can increase risk. Fragile veins, often seen in the elderly or those with frequent venipuncture, are more susceptible to puncture and leakage. Patient cooperation is also a consideration, as an inability to report discomfort, due to sedation or altered mental status, delays the recognition of an injury.
Selecting the appropriate vein and location for the catheter is a foundational preventative measure. Peripheral access should prioritize veins in the forearm or the dorsum of the hand, starting with the most distal sites first. Sites over areas of joint flexion, such as the wrist or the antecubital fossa, should be avoided because movement increases the chance of catheter dislodgement or vein wall perforation. Locations directly over bones or tendons are poor choices, as the lack of subcutaneous tissue offers minimal fluid dispersal, concentrating the vesicant and risking structural damage.
The choice of catheter must be proportional to the vein size and the therapeutic need. Clinicians should select the smallest effective gauge to minimize trauma to the vessel wall, such as a 20- or 22-gauge catheter for most adult infusions. Matching the catheter to the vein diameter allows sufficient blood flow around the device tip, facilitating rapid dilution of the infusate and reducing vessel irritation. Compromised limbs, such as those affected by a dialysis fistula or post-mastectomy lymph node dissection, must be avoided entirely due to altered circulation and increased vulnerability.
Proper Technique During Infusion
The mechanical act of catheter insertion and subsequent securement are important steps in the prevention process. After insertion, confirmation of adequate blood return into the catheter hub verifies correct placement within the vein. This confirmation should be repeated throughout the procedure, especially before and after medication administration. Insertion attempts requiring multiple venipunctures are discouraged, as this compromises vessel integrity and increases the risk of extravasation.
Once venous access is established, the catheter must be stabilized firmly to prevent micro-movement that could erode the vein wall. Stabilization is achieved using specialized securement devices or sterile, transparent dressings that allow for continuous visual inspection. Clear dressings facilitate frequent assessment of the surrounding skin for early signs of trouble. The patient should be educated to immediately report any sensation of pain, burning, stinging, or coolness at the IV site.
Continuous vigilance is mandatory throughout the infusion, particularly for high-risk medications. The integrity of the access site is monitored actively by the clinician. For infusions involving vesicant drugs, the site should be checked frequently, often every five to fifteen minutes during administration, for swelling, blanching, or a change in skin temperature. Maintaining the prescribed infusion rate is necessary, as rapid administration increases the pressure within the vein, potentially leading to a rupture and forcing the drug into the extravascular space.
Special Handling for Vesicant Medications
Vesicant medications possess chemical properties, such as a pH below 5 or above 9, or a high osmolarity exceeding 600 mOsm/L, which make them highly corrosive to tissue if they leak. For prolonged or continuous infusions of these high-risk agents, the use of a central venous access device (CVC) or a peripherally inserted central catheter (PICC) is strongly preferred. These devices terminate in the superior vena cava, allowing for immediate blood flow dilution, significantly mitigating localized tissue damage.
If peripheral access is the only option, a freshly placed catheter is required for vesicant administration, as older lines have an increased risk of failure. Peripheral sites must be restricted to larger, more robust veins. The small, delicate veins of the hand, wrist, or digits should never be used due to the limited subcutaneous fat available to absorb the extravasated drug. Vesicant administration should also occur before other medications to ensure the vein is not already irritated or compromised.
High-risk vesicant categories include certain chemotherapeutics, vasopressors, and high-concentration electrolyte solutions. Chemotherapy agents like Anthracyclines (e.g., Doxorubicin) and Vinca Alkaloids (e.g., Vincristine) are highly cytotoxic. Vasopressors, such as Dopamine and Norepinephrine, cause intense local vasoconstriction leading to tissue ischemia. Highly concentrated solutions, like Dextrose greater than 10% or Calcium Chloride, cause cellular dehydration due to their high osmolarity. Before starting any infusion of a vesicant with a known pharmaceutical antidote, the antidote medication, such as Phentolamine for vasopressors or Dexrazoxane for Anthracyclines, must be immediately available at the bedside to ensure a rapid response.
Emergency Response Protocol
If extravasation is suspected, an immediate and systematic response is necessary. The first step is to immediately stop the infusion or IV push. The clinician should then notify the supervising provider and pharmacy without delay to initiate the specific treatment plan.
The catheter should not be flushed, as this action would only push more of the vesicant drug into the compromised tissue. Instead, the catheter is left in place temporarily to attempt to aspirate any residual drug from the device and the surrounding extravascular space. Once aspiration is complete, the catheter is carefully removed unless it is needed for the administration of a pharmaceutical antidote directly into the injury site.
The affected extremity must be elevated immediately above the level of the heart to promote venous and lymphatic drainage, which reduces localized swelling. Local thermal treatment is then applied based on the specific vesicant drug involved. Cold compresses are typically applied to limit the spread of vesicants like Anthracyclines, while dry heat is used to disperse vasoconstrictive agents like Vasopressors. Thermal treatment is often applied for cycles of fifteen to twenty minutes, repeated every four hours for the first twenty-four to forty-eight hours, according to the drug-specific protocol.